Examination of the periodontium

includes: 1. a visual examination of gingiva includes changes in color and shape, bleeding without apparent reason 2.probing of gingival sulcifor pathologic deepening associated with periodontal disease 3.review of full mouth radiographs and posterior bitewing x-ray for lamina dura continuity and alveolar crest bone height

PERIODONTIUM
GINGIVA ALVEOLAR BONE PERIODONTAL LIGAMENT CEMENTUM

GINGIVA
>is divided into free, attached and interdental papillae Structures: 1.Free gingiva unattached coronal portion of the marginal gingiva on the facial and lingual surfaces

2.Interdental papilla located between proximal surfaces beneath contact points. COL saddle like depression joining 2 pyramid shaped papilla, 1 on facial and 1 on lingual

3.Free gingival groove a shallow linear

depression demarcates the free gingiva from the adjacent attached gingiva.

4.Attached gingiva consists of stippled tissue tightly bound down to the underlying bone and cementum of the tooth and extends from free gingival groove to the mucogingival junction which demarcates it from alveolar mucosa

5. Gingival sulcus the space between the free gingiva and the tooth surface. potential space encircling the tooth sulcus depth varies from 0.5 3mm.

CLINICAL SIGNS OF A NORMAL GINGIVA 1.Color dependent on the ff. a. vascularity of mucosa b. hemoglobin in blood c. attachment of CT d. width of epithelium e. degree of keratinization f. pigmentation of epithelium g. presence/absence of inflammation.

Take note:
The normal and healthy attached and free gingiva are uniformly CORAL PINK throughout the mouth Physiologic pigmentation, either diffuse or localized may alter the shade and uniformity of color of both primary and adult dentition.
Localized pigmentation: may cause a variation from light brown to dark blue. Diffuse pigmentation or generalized pigmentation modifies the shade of the gingiva in direct proportion to the color of the skin.

The gingiva is most often a Pale Coral Pink in the primary dentition but may contain areas of whiteness and redness associated with eruption of teeth during mixed dentition period. The pale pink color that turns to white on pressure(blanching) denotes a healthy gingiva.

2. Form and contour of interdental papillae (triangular), free gingiva margin and attached gingiva should fill the interproximal space and end in a knifelike edge closely adapted to the surfaces of teeth. related to morphology of tooth crown, spacing of teeth, contour of roots and presence of disease

3.Density or consistency depends on location, attachment and disease -normally firm, resilient, tightly bound to alveolar process except at free margin and interdental papilla borders on palpation : attached gingiva should feel primarily the contours of underlying bone and slight movement or resiliency of the interposed attached gingiva. surface palpation and light rubbing will reveal the degree of stippling and some extent the degree of keratinization. free gingiva should yield slightly more to pressure and give a faint sense of movement

STIPPLING -A protective adaptation to function -Orange peel / skin appearance

4.Depth

during active eruption, averages 0.5-3mm in adults, no bleeding on gentle probing

sulcus may vary

of gingival

5.Attachment normal

attachment should be on enamel or at CEJ, in elders should not be more than 1mm below CEJ

FINDINGS IN DISEASE

Principal clinical changes in periodontal diseases includes the following:

1.altered color- changes in color of the gingiva may result from any alteration of factors that are responsible for its normal pink color. Examiner should records this findings bec. The significance of this is not only for diagnosis of disease but also for evaluation of periodontal theraphy. Changes in color may usually associated with acute or chronic inflammation or it may associated with the generalized diseases.

Examples: pale gingiva, buccal mucosa, palate, lips conjunctiva and finger nailbeds may be related to patients with ANEMIA. general redness of gingiva, buccal mucosa,palate and tongue indicates SENSITIVITY MANIFESTATION. when it includes general redness of face, hands, neck POLYCYTHEMIA.

melanosis of the gingiva, buccal mucosa, palate indicates ADDISONS DISEASE

bluish cast to the gingiva, buccal mucosa, palate, tongue, hands and face may indicate CENTRAL OR PERIPHERAL CYANOSIS
alteration of color as a result of inflammation is related to CHRONICITY of the injurious agent and a response of tissue to irritation

acute inflammation gives rise to a bright red erythematous discoloration. accretions, films, plaques and necrotic tissue may also alter the color.

toothpastes and drugs

grayish slough easily removed suggests necrosis with pseudomembrane formation indicates ANUG granulation tissue gives red discoloration and once it subside, forms a scar tissue, discolors to a white gingiva

for dark races, melanosis of the other surface mucosa aside from the gingiva is noted

metallic pigmentation or amalgam tattoo is noted on the extraction site near a large amalgam restoration

2.Gingival bleeding even with gentle probing

3.Altered gingival form

4.Increased sulcular depth 5.Attachment apical to the CEJ

PERIODONTAL DISEASE
1.Simple gingivitis 2.Complex gingivitis a.Vincents infection (necrotizing ulcerative, ulceromembranous) b. hyperplastic gingivitis b1.simple hyperplastic gingivitis b2.hereditary gingivofibromatosis c.gingivitis modified by systemic factors b3i.dilantin hyperplasia b3ii.pubertal gingivitis b3iii.pregnancy gingivitis d.leukemic gingivitis

3.Gingivostomatitis a. chronic desaquamation gingivitis b. herpetic gingivostomatitis 4. Gingival atrophy and recession a. chronic atrophic senile gingivitis b. atrophic gingivitis

1.Simple gingivitis
This is an acute or chronic inflammation cause by poor oral hygiene or local irritation. Alteration of the color, form and density of the tissue is due to response to the injury. some degree of gingival enlargement is present but not extensive. Changes may involve few area of free gingival margin.

2. Complex gingivitis a.Vincents infection(ANUG)

It is characterized by necrosis of the gingival margins and interdental papilla, w/c leaves punchedout craterlike depressions. The surfaces of the lesion is cover w/ gray or grayish yellow pseudomembrane that is easily removed, leaving a bleeding ulcerated surface, the margins of lesions present a pronounced erythematous appearance. Sign and symptoms: pain of varying degrees , sialorrhea, wedging sensation of teeth, and foul breath,local lymphadenopathy is likely to present. Fever, malaise, anorexia and other systemic manifestation may be present.

b. hyperplastic gingivitis b1.simple hyperplastic gingivitis

This is a simple enlargement of the gingiva especially the free gingival margin & interdental papilla, resulting from chronic irritation. The most proliferative response of tissue is more pronounced than in simple gingivitis, the tissue is soft and spongy, the color is bluish red

b2.hereditary gingivofibromatosis This is a progressive proliferative process in w/c the normal contour & form of the gingiva are altered. The tissue is generally pale pink, firm and very dense, the enlargement is also pronounced as to completely cover the teeth. The tissue tend to return progressively after surgical removal even in the absence of local irritation.

c.gingivitis modified by systemic factors

c1.dilantin hyperplasia This is a progressive proliferation of the gingiva associated with phenytoin theraphy. Clinical signs and symptoms is similar to those simple hyperplastic gingivitis, to make diagnosis it is necessary to know the patient is taking phenytoin sodium. Local irritants cause the inflammatory respose, phenytoin only exaggerate this response, w/ resultant gingival enlargement.

c2.pubertal gingivitis Gingival enlargement is associated w/ hormonal imbalance, changes in color, form, and density changes are the same in the simple hyperplastic gingivitis.

c3.pregnancy gingivitis
The gingival enlargement showing all signs and symptoms of simple hyperplastic gingivitis plus a greater tendency to bleed.

Associated with Endocrine puberty, menstrual cycle, pregnancy

d.Leukemic gingivitis Characterized by pronounced gingival enlargement w/c is primarily caused by the infiltration of the o the gingival tissues by neoplastic blood cells, which produces peculiar thickening of the gingival margins. The color may be bluish-red to pink. The tissue is generally soft and spongy. Spontaneous and persistent hemorrhage occurs frequntly. Reginal lymphadenopathy may present.

3.Gingivostomatitis a. chronic desaquamation gingivitis

Associated by altered premenopausal hormonal stimulation. Occasionally seen on male. Color of gingiva varies from one location to another from grayish blue to brilliant red. There is patch of speckled discoloration. In some cases entire gingiva is erythematous, gingiva is soft, pain is common symptom.

b. herpetic gingivostomatitis This is an acute process caused by the initial invasion of any or all the oral mucosa by the herpes simplex virus. Early features include regional lymphadenopathy, fever, malaise and sore throat,the last is dysphagia. There are generalized gingival hyperemia, tenderness, and usually vescicles. Lesions may follow the initial systemic phase. The disease is self-limiting, lastingfrom about a week to10 days.

4. Gingival atrophy and recession a. chronic atrophic senile gingivitis b. atrophic gingivitis

Periodontitis
as manifestation of systemic disease Associated with hematological disorders, genetic disorders, necrotizing periodontal disease, abscess, endodontic lesion, developmental or acquired deformities

Alteration of Alteration of color form Red or bluish red

Clinical feature/s

Symptom

Soft and Periodontal Localized spongy with pockets Or rolled thick Loss of bone generalized margins and attachment

RADIOGRAPHIC SURVEY
1 Height and form of interdental alveolar bone crest 2 Lamina dura (continuity) 3 Status of interradicular areas 4 Overhanging margins 5 Width of periodontal ligament space 6 Periapical bone status, roots

PERIODONTAL CHART
should include the following: 1. record level of free gingival margin 2. depth of periodontal pockets 3. level of bone around the teeth 4. tooth mobility, malposition and loss dental caries, plaque and calculus index periodontium status

CHARTING
1 A record of level attachment and position of the free gingival margin relative to the CEJ is measured. Walk the probe around the teeth. 2 Measurement is made at six points mesial,center,distal of buccal or labial surfaces; mesial,center,distal of lingual surfaces

3 Free gingival margin drawn on the dental chart with 1mm graduations. 4 Use a calibrated probe marked at 3,6 and 8mm, probing the depth of each gingival sulcus to determine if it exceeds the acceptable 3mm depth.

Periodontal chart & probing

5 Mobility of all teeth should be tested in terms of numerical reference 1st distinguishable sign of movement , normal 2nd movement of 1mm from normal in any direction 3rd mobility in any direction more than 1mm rotation or depression

OTHER DIAGNOSTIC METHODS

1 Gingival sulcular fluid flow & composition 2 Microbiologic test detects predominant bacteria in the lesion 3 Immunologic method immune response 4 Organulocytic migratory rate evaluate severity of gingivitis 5 Blood studies differential white cell count leukemia gingivitis & neutrophil dysfunctioncyclicneutropenia,agranulocytosis ,Chediak-Higashi disease.